Managing Patients with

CKD in Primary Care: A Shared Care Pathway

5th April 2018

Learning Objectives

Reference: Kerr, M et al (2012) Estimating the financial cost of chronic kidney disease to the NHS

in England. Nephrol Dial Transplant

1) What health risks does CKD represent?

2) Why change how we manage CKD in NWL? 1) How do we improve CKD management in NWL?

ACR=albumin:creatinine ratio; CKD=chronic kidney disease; eGFR=estimated glomerular filtration rate; GFR=glomerular filtration rate. Adapted from: NICE (2014) Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care (CG182). Available at: http://www.nice.org.uk/cg182 (accessed: 29.09.2014)

GFR and ACR categories and risk of adverse outcomes

ACR categories (mg/mmol), description and range

<3 Normal to mildly

increased

3–30 Moderately increased

>30 Severely

increased

A1 A2 A3

GFR

cat

ego

rie

s (m

L/m

in/1

.73

m2),

d

esc

rip

tio

n a

nd

ran

ge

≥90 Normal and high

G1

60–89 Mild reduction related to normal

range for a young adult

G2

45–59 Mild–moderate reduction

G3a

30–44 Moderate–severe reduction

G3b

15–29 Severe reduction

G4

<15 Kidney failure

G5

Increasing risk

Incre

asin

g ris

k

Nice Guidance Classification

Chronic kidney disease

Increased cardiovascular mortality in renal disease

USRDS data; Levey et al, AJKD, 1998

Dialysis patients

Normal population

Incidence of end-stage renal disease

206

165

122

146

103

180

114

115

Renal Registry, 2016 Report

UK = 120

per million population (pmp)

Observations

Reference: Kerr, M et al (2012) Estimating the financial cost of chronic kidney disease to the NHS

in England. Nephrol Dial Transplant

• Cardiovascular disease remains associated with CKD with increased

mortality

• Estimated annual cost of managing an individual’s:

• CKD = £235

• Transplant = £12,000

• Dialysis = £27,000

• Significant number of patients have non-progressive CKD who do not

require specialist input

West Midlands Experience

Rayner et al, NDT 2013

CKD pathway redesign in NWL

Aims: 1. Reduce incident ESRD growth 2. Stabilise prevalent ESRD cohort in NWL 3. Reduce unnecessary clinic attendance 4. Increase discharges from secondary care 5. Improve care & experience of CKD in NWL 6. Support self management and community care Identify and focus upon those at risk Ensure that patients are treated according to NICE guidance to reduce or

prevent progression across the system Improve the efficiency of care for patients with CKD Improve the planning for ESRD management for those that deteriorate

Activities

CKD shared care programme and pathway re-design with virtual clinics

E-advice service

Consultant outreach into primary care (CC4A: Connecting Care for Adults with long term conditions)

Current Engagement

Constituents of the pathway

LOCAL GUIDELINES

Referral criteria

Transfer from

secondary care follow-

up

Discharge information

Maintenance in primary

care

Quality standards

Constituents of the pathway

LOCAL GUIDELINES

Referral criteria

Transfer from

secondary care follow-

up

Discharge information

Maintenance in primary

care

Quality standards

• NICE guidance

• Electronic referral forms

• Supported by e-advice

CHRONIC KIDNEY DISEASE – REFERRAL ALGORITHM Endorsed by CWHHE Diabetes Strategy

Group

eGFR<60

Is patient unwell?

Manage acute illness Is this acute kidney injury (AKI)? Repeat eGFR within 1 week, refer urgently if declining

Urine dipstick

YES

Persistent haematuria (≥1+)?

Urology referral

Is malignancy excluded?

Nephrology advice/referral ACR >70?

Repeat eGFR stable?

Nephrology advice/referral if declining

• Sustained decrease in GFR of ≥ 25% within 12 months

• Sustained decrease in GFR of ≥ 15ml/min within 12 months

What is cause for CKD?

Seek nephrology guidance if this is uncertain

STAGE G3a and G3b

Monitor according to page 3

Most patients with CKD 4/5 should be being followed in secondary care HOWEVER – if RRT not indicated (eg. frail elderly), management of advanced CKD may be appropriate in primary care

YES

NO

NO

NO

NO

YES AND > 50 YRS

YES AND < 50 YRS

YES

URGENT REFERRAL • Suspected multisystem disease with

evidence of renal involvement

• Acute kidney injury (without an obvious cause manageable in primary care)

• Newly diagnosed eGFR < 15

• Nephrotic syndrome

• Accelerated hypertension

• Severe hyperkalaemia (>6.5mmol/L)

Minimum information for referral • Dates and results of previous

creatinine/eGFR measurement • Medical history • Drug history • Current BP • Urine dipstick and ACR if dipstick

positive Renal Ultrasound if: • accelerated progression of CKD • visible or persistent invisible

haematuria • symptoms of urinary tract obstruction • family history of polycystic kidney

disease and are aged over 20 years • eGFR of <30 ml/min/1.73 m2 (GFR

category G4 or G5)

STAGE G4 - 5

Email advice from nephrology consultants is available to North West London primary care services: • ICHC-tr.ckdadvice@nhs.net

DraftV6.0 Date of preparation: March 2018. For review: April 2018

14

Constituents of the pathway

LOCAL GUIDELINES

Referral criteria

Transfer from

secondary care follow-

up

Discharge information

Maintenance in primary

care

Quality standards

• Unlikely to require

specialised renal

intervention

Constituents of the pathway

LOCAL GUIDELINES

Referral criteria

Transfer from

secondary care follow-

up

Discharge information

Maintenance in primary

care

Quality standards

• General practitioner

• Patient

GPs receives a discharge letter informing them

Patient suitable for community management

Guidance for monitoring and frequency

Criteria for re-referral

Copy of patient information sheet and letter

Notification that the patient will be entered onto the quality audit database

Patients receive

Discharge letter

Information sheet with advice on management of cardiovascular risk

Contact information and useful website flyer

Notification that they will be entered onto the quality audit database

Discharge Pack

Constituents of the pathway

LOCAL GUIDELINES

Referral criteria

Transfer from

secondary care follow-

up

Discharge information

Maintenance in primary

care

Quality standards

• Lifestyle

• Vein preservation

• BP <140/90

• RAAS blockade

• Monitor eGFR

Endorsed by CWHHE Diabetes Strategy Group

CHRONIC KIDNEY DISEASE – ONGOING MANAGEMENT

MANAGEMENT OF STABLE CKD FREQUENCY OF MONITORING eGFR (NUMBER OF TIMES PER YEAR)

Agree management plan with patient Lifestyle advice (Exercise/Weight/Meditation) Smoking cessation advice BP: • Encourage home BP monitoring • Target BP: < 140/90 if ACR ≤ 70 < 130/80 if ACR > 70 • Caution of BP targets in frailty (See page X) • Prioritise ACEi/ARB with associated sick day guidance Cardiovascular risk: • Aspirin – if CV risk at 10yrs >20% • Proton-pump inhibitors (PPIs) – esp. if higher risk of

gastric irritation with aspirin. Observational data suggest PPIs may cause insidious inflammatory kidney injury –switch to ranitidine if eGFR falling

• Statins – treat according to national guidelines Avoid NSAIDs Vaccinate for influenza and pneumococcus

GFR and ACR categories and risk of adverse outcomes

ACR categories (mg/mmol) description and range

Incr

eas

ing

risk

<3 Normal to mildly

increased

3-30 Moderately increased

>30 Severely increased

A1 A2 A3

GFR

cat

ego

rie

s, d

esc

rip

tio

n a

nd

ran

ge

≥ 90 Normal and high

G1 ≤1 1 ≥1

60-89 Mild reduction related to normal range for a young adult

G2 ≤1 1 ≥1

45-59 Mild-moderate reduction

G3a 1 1 2

30-44 Moderate-severe reduction

G3b ≤2 2 ≥2

15-29 Severe reduction

G4 2 2 3

≤15 Kidney failure

G5 4 ≥4 ≥4

Increasing risk

RENIN-ANGIOTENSIN SYSTEM INHIBITORS IN CKD (ACEI and ARB)

RENAL ANAEMIA

• ACEi and ARB prevent scarring in CKD and should be used preferentially in patients with proteinuria • Assess kidney function and electrolytes. 1-2 weeks after initiating therapy, watch out for hyperkalemia • Assess kidney function after any subsequent increase in dose • A small rise in creatinine or a mild fall in eGFR values is expected with therapy – repeat the assessment of kidney function

if the rise in creatinine is greater than 15% • STOP therapy - If serum creatinine rises by >30% or eGFR falls by >25% fall seek specialist advice (to exclude possible

renovascular disease) • If K>6.0 stop ACEi/ARB and start low potassium diet – if the patient has proteinuria and would benefit from an ACEi/ARB

seek Nephrological advice as introduction of frusemide or bicarbonate can facilitate reintroduction of these agents • Cautious use of ACEi/ARB with spironolactone and other potassium sparing diuretics, very close monitoring of potassium

required.

Patients with progressive CKD can develop renal anaemia which usually manifests from CKD3b and beyond. This may require treatment with erythropoietin. Renal anaemia should only be diagnosed after exclusion of other causes including iron deficiency, folate or B12 deficiency, haemolysis. Renal anaemia is unusual prior to CKD3b but if suspected, nephrology advice should be sought.

DraftV6.0 Date of preparation: March 2018. For review: April 2018

19

Sick Day Rules

When unwell: • Vomiting / diarrhoea • Unable to eat / drink • Fevers

Miss out for 2-3 days: • ACE-inhibitors (ACEis) • Angiotensin-receptor blockers (ARBs) • Direct renin inhibitors (eg. Aliskerin)

• Sodium-glucose cotransporter-2 inhibitors (SGLT2) • Diuretics

• Non-steroidal anti-inflammatory drugs

• Metformin • Sulphonylureas (eg. gliclazide) • Short-acting insulin

After 2-3 days: • Feeling better = resume medications

• No better = seek medical attention

Endorsed by CWHHE Diabetes Strategy Group

CHRONIC KIDNEY DISEASE – COMMON DRUGS

V6.0 Date of preparation: March 2018. For review: April 2018

21

ANTIBIOTIC Issue in reduced kidney function Recommendation for use

Trimethoprim Raises serum potassium and creatinine ~20% (affects tubular function but not nephrotoxic per se)

Safe for use if eGFR>30 but may transiently elevate K and creatinine – repeat bloods 1-2 weeks later to ensure resolution

Nitrofurantoin Requires filtration and tubular secretion. Reduced excretion in CKD and high levels cause peripheral neuritis

Do not use if eGFR<45. May cause toxicity and not reach high enough urinary concentrations to be effective

Penicillin Risk of crystalluria Generally safe but avoid maximum doses if eGFR<15

Macrolides (eg. Clarithromycin)

Renally excreted, can cause neurotoxicity Reduce dose by 50% when eGFR<30

Quinolones (eg. Ciprofloxacin) Renally excreted, risk of tendonopathy and potentially nephrotoxic Reduce dose by 50% when eGFR <15

Tetracyclines Partly renally cleared; doxycycline safer Reduce dose when eGFR<45

HYPOGLYCAEMIC AGENT eGFR = 45-59 (CKD stage 3a)

eGFR = 30-44 (CKD stage 3b)

eGFR <30 (CKD stage 4-5)

Metformin Safe to use Reduce dose Stop

Gliclazide Safe to use

Safe to use Use with caution; reduce dose

DPP-4 inhibitors (eg. Linagliptin, Sitagliptin)

Safe to use Adjust dose according to licence (only Linagliptin unchanged = 5mg OD)

Adjust dose according to licence (only Linagliptin unchanged = 5mg OD)

SGLT-2 inhibitors (eg. Canagliflozin, Empagliflozin)

Reduce dose (Cana- and Empa-gliflozin) Stop Dapagliflozin

Stop Stop

GLP-1 inhibitors (eg. Liraglutide, Exanatide)

Adjust dose according to licence Adjust dose according to licence

Stop if eGFR<15 (Liraglutide, Dulaglutide safe if eGFR>15)

Pioglitazone Safe to use Safe to use

Safe to use

Proton-pump inhibitors (PPIs)

• Should be considered if there is a higher risk of gastric irritation with aspirin or when the patient has more advanced CKD (eGFR <20) • Observational data suggest PPIs may cause insidious inflammatory kidney injury – therefore switch to ranitidine if eGFR falling whilst on PPIs

Constituents of the pathway

LOCAL GUIDELINES

Referral criteria

Transfer from

secondary care follow-

up

Discharge information

Maintenance in primary

care

Quality standards

• BP target achieved

• eGFR measured within 12 mths

• Change in eGFR managed

1 year follow-up data

•Using Whole Systems Integrated Care (WSIC) platform

•Available data for 66% of patients

•Of those:

•74% within 1yr (+/- 3 mths)

•92% within 1yr (+/- 6 mths)

Medians (range) 2015 (transfer) 2016 (1yr follow-up)

systBP 131 (107-196) 132 (95-168)

diastBP 76 (52-103) 77 (50-107)

sCreatinine 135 (69-243) 131 (71-279)

eGFR 42 (25->90) 42 (14-71)

Change in eGFR at 1 year (median = 0 mL/min/1.73m2)

-20

-15

-10

-5

0

5

10

15

20

25

30

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65

17 individuals >5mL/min/m2 eGFR fall in 1 yr (26% of 66 total)

LOCAL GUIDELINES

Education sessions in community

Educational literature

PATIENT education

Supported by:

ICHC-tr.ckdadvice@nhs.net

CURRENT STATUS

• >30 community education CKD sessions delivered • >700 patients transferred from renal OPD into

shared care • E-advice service feedback and clinic attendance

avoidance • Re-organisation of HH and CXH Nephrology

services – freeing up capacity to increase service available for patients with stage 4 CKD / near ESRF as well as supporting patients to continue care out of hospital

Imperial CKD email advice service

• Explicitly for questions on CKD

• Guaranteed answer in <24 hours weekdays

• Rotation of 4 consultants

• Unfunded

Imperial CKD email service: data

• Over 10 months Jan – Nov 2016: 105 emails (0.5 emails / working day)

• Mean response time 23 hours

• Most common Qs: Risk factor modification (20%) Referral triggers (19%) Prescribing (19%) Management of decline in GFR (18%) BP (17%) Radiology advice (9%)

Zaman et al 2017

Imperial CKD email service: data

Number of GPs requesting referral to Nephrology outpatient clinic

21 (20%)

Advised to refer to Nephrology clinic at that point

2 (10%)

Advised that referral currently not required 17 (81%)

Triggers for future referral identified 9 (43%)

Advised to refer to another speciality clinic 2 (10%)

Zaman et al 2017

Imperial CKD email service: data

• GP satisfaction: (41% response rate) 100% would recommend to colleague 100% satisfied with response and timeliness 67% would have referred patient to OP if not used the email service (=30 patients in sample) 10% would have sent patient to ED (4 patients)

• “the clearest advice of all the email advice services”

Zaman et al 2017

Virtual Triaging / Clinic

GP reviews patient and decides on referral

Records encounter on EMIS / S1

Obtains and records consent to share data

Referral made through ERS

Nephrologist reviews EMIS / S1 record

Records encounter on EMIS / S1

Letter to patient

Advice / vClinic / Ix / F2F /

Primary Care Secondary/tertiary Care

Thank you

Email advice: ICHC-tr.ckdadvice@nhs.net

Website / resources: http://www.hounslowccg.nhs.uk/what-we-do/improving-ckd-care.aspx